EMT-Chapter 14 Street Scenes

Satisfied there are no life threats for which you have to provide immediate intervention, you determine this patient's priority to be medium in severity with the potential to get worse. "What's your name?" you ask. It turns out she had exercising on the treadmill. you note that she speaking in complete sentences and does not have to stop ever few words to catch her breath. You ask Juan, your partner, to begin administering oxygen by way of a NR mask. While Juan is doing that, you continue your examination. 3. What part of the secondary assessment should follow next?

Ask the OPQRST questions and ask specific questions about her previous medical history. Of particular importance is the use of an inhaler or other medications commonly prescribed to asthma patients.

2. What questions should you ask the patient and her husband?

At this point, you should complete a history of the present illness. Questions might include following: Has the patient had a similar condition in the past? Is the patient taking any blood pressure medication? If so, what is the medication? Is the patient complaint in taking it? In specificanlly questioning the husband, you might ask: "When was the last time you saw your wife?" "Was she manifesting any of current signs or symptoms at that point, such as trouble walking slurred speech, or obvious facial dropping?" In specifically questioning the patient, you might ask: " Are you having any trouble breathing?" "Are you in any pain?"

3. How do the medications impact your history taking and decision making?

Knowing the medication patients are taking can often tell you a lot about their history and the illnesses they're being treated fo r. YOu might also be able to determine when the patient last took his medication for his diabetic condition

2. What body systems may be involved in causing this altered mental status?

Mr. Ronson could be having a diabetic emergency, a neurologic emergency such as a CVA or TIA, or a cardiac emergency such as a heart attack or hypertensive crisis.

CRITICAL THINKING AND DESICION MAKING You are called to a patient with an altered mental status at an assisted living facility. The staff tells you that Mr. Ronson is normally very active and vibrant. "like the mayor of this place." But today he just isn't himself. He just sits in the chair and doesn't talk. "It is so unlike hime," they say. You arrive at the patient's side and introduce yourself. The patient turns his head toward you and acknowledges you with a grunting noise. His color appears OK. He is breathing deeply and regulary. His radial pulse is strong at about 60 b/m and regular. You quickly check his pulse oximetry reading and it is 96%. You palce him on 2 liters of oxygen via NC. The attendant gives you a list of medications taken by the patient. They tell you he is a diabetic and has had 2 heart attacks and one stroke. He also has high blood pressure and high cholesterol. 1. Assuming that your primary assessment is completed, what would be your next assessment steps?

Once the primary assessment is complete, proceed with a secondary assessment to assess the patient's mental status, check for any pain or discomfort, and consider using the Cinncinnati Prehospital Stroke Scale to rule out signs of stroke.

REASSESSMENT You receive a call for an elderly woman with a possible stroke. After taking the appropriate Standard Precautions, you ensure scene safely and enter the house. An older man, identifying himself as the patient's husband, meets you at the door. As he leads you to the kitchen, he explainsthat he came home after being out for a while and found his wife unable to stand up. When you reach the kitchen, you find Althea Stokes sitting in the chair. Your general impression is of an elderly woman who appears awake but is slumped onto her left side. As you introduce yourself, you notice the patient's eyes are open and awake, but her speech is slow and slurred. She does not appear to be in pain. A smalll amount of saliva is drooling onto her blouse. Her airway is open; breathing appears normal unlabored; there is no sign of bleeding; and her radial pulse is strong, slightly rapid, and very irregular. You assing Mrs. Stokes a medium priority as a medical patient. In your basic-life support system, calling for Advanced Life Support is not an option. 1. How does the patient's mental status affect the way you maintain the patient's airway?

Patients who are less than alert may have difficulty maintaining their airways. These patients may be positioned in such a manner as to occlude their anyways through a partial blockage by the tongue- a condition that can be resolved by repositioning. Also, with less than alert patients, you need to be prepared for suctioning. You may also need to move these patients into a position that will facilitate drainage. Any patient who is unresponsive or poorly responsive must be monitored constantly. Be prepared to reposition the patient as needed and intervene with airway adjuncts such as OPAs or NPAs as necessary to control the airway. Have suctioning equipment immediately available.

You wipe the saliva away from the patient's mouth and consider how to maintain her airway. If she loses consciousness, you should be prepared to suction. In the meantime, you make a mental note to keep an eye on further potential threats to her airway. Since the patient is having difficulty speaking, you get most of the history from Mr. Stokes. His 82 year old wife is usually alert and very active, he informs you . She was fine when he left about 4 hours ago but when he came home, she was slumped over in the chair and couldn't seem to move her left arm and leg. When you ask Mrs. Stokes if she having any pain or difficulty breathing, she slowly responds with slurred speech,"No, I'm not." As your partner gathers vital signs, you look at the patient more carefully. The right side of her face seems to be drooping, especially her cheeck and upper eyelid. When you ask her to hold her arms out in front of her, she picks up her right arm but can barely move her left one. When you ask her to smile, only the left side of her face moves. Her pupils are equal and reactive to light. Her vital signs are pulse 92 and irregular, blood pressure 180/96, respirations 20 and unlabored. According to Mr. Stokes, the only medical problem his wife has is high blood pressure, for which she takes just one medications, Vasotec. She has no allergies to medications. She is a patient of Dr. Newman and has not been hospitalized recently. Because her brain might not be getting enough oxygen, you give her 12 liters per minute by NR mask even though she has oxygen saturation of 98%. You take special care to put Mrs. Stokes on her left side on the stretcher so she is able to still move her right arm and saliva will not obstruct her airway. 3. How should you perform a reassessment on this patient? En route, you contact the receiveing hospital and report on the patient's conditon and treatment. You repeat her vitals signs and this time get a pulse of 88 and irregular, blood pressure of 170 by palpation, and respirations of 22 and unlabored. When you ask the patient how she feels now she replies, in a clear voice, "Why much better, young man." Surprised at this sudden improvement, you proceed to assess her again. She can now hold both arms up in front of her with her eyes closed. When she smiles, ther is no longer any sign of a deficit. Cheered up by this turn of events, you confirm that her husband's version of events is accurate. You also learn that Mrs. Stokes has led an interesting life, having been a history teacher for 40 years. About 5 minutes after this improvement, you notice that the patient seems to be having trouble speaking again. When you ask her to hold her arms out in front of her, she is able to pick both of them up, but her left arm drifts off and falls down. Her smile barely shows her teetch. When you ask her to repeat the phrase, "The sky is blue in Cinncinnati," she can get only the first few words out and only with great difficulty. Concerned about these changes in the patient's condition, you call the hospital again and advise them of the developments. When you arrive at the emergency department a few minutes later, Mrs. Stokes conditon has not changed again. the nurse undressess her and the emergency physician assesses her as you prepare the ambulance for the next call and complete your PCR (patient care report). Just as you are finishing the report, the doctor comes out of the patient's room, "Well, I'm glad you brought this patient here, " he says. "She's not a candidate for clot-busting drugs but since this is a teaching hospital, we can offer Mrs. Stokes the opportunity to participate in a research project evaluating a new experimental treatment for stroke." "Do you think she's really having a stroke?" you ask "Her condition kept changing, getting better and then getting worse again." Knowing that understanding the manifestation of a disease in a patient is an important part of quality improvement, the doctor tells you, "We often see changes in the condition of stroke patients in the first few hours of the episode. It can make assessmane a real challenge. I'm glad you were able to detect the changes and let us know about them." With a new appreciation for th value of a reassessment you return to your service area, ready for another call.

Reassessment includes continually monitoring the patient's airway, breathing and any changes in her level of consciousness. Periodically reassess the patient's speech, and observe for facial drooping. Reassess the patient's pupils and vital signs every 5 minutes. Periodically reevaluate changes in movement, strength, and sensation in all extremities.

Satisfied there are no life threats for which you have to provide immediate intervention, you determine this patient's priority to be medium in severity with the potential to get worse. "What's your name?" you ask. It turns out she had exercising on the treadmill. you note that she speaking in complete sentences and does not have to stop ever few words to catch her breath. You ask Juan, your partner, to begin administering oxygen by way of a NR mask. While Juan is doing that, you continue your examination. 4. What signs or symptoms would you look for to determine if the patient was getting better or worse? "What do you think caused your shortness of breath?" you ask. She replies that she's had a mild case of asthma for about 10 years and that it is exercise induced. You ask how long she has been having trouble breathing with this episode. "About 10 minutes," she replies. You know that many asthmatics carry their own medication for asthma, so you ask what medications she is taking. "I have an inhaler, but I left it at home. I think it's called Albutterball or something like that," You suggest the name albuterol," and she nods her head. Meanwhile, Juan places the oxygen maks on Andrea's face. You ask if she is allergic to anything, and she shakes her head no. While you listen to lung sounds, Juan obtains basline vitals. You note that the lung sounds are equal but noisy, like a whistling sound. Juan informs you that her pulse is 120 and regular: skin is warm and dry; respirations are 24 and slightly labored; and her blood pressure is 130/70. her oxygen saturation is 96%. Andrea accepts your offer to transport her to the emergency department, so you put her on the stretcher in her position of comfort, sitting up. During the short trip to the hospital, you use the radio to inform the emergency department of your patient's condition and treatment, take another set of vital signs and reassess the patient. She appears to be a little better, but her breathing is still slightly labored and is little noisy. She does not have any signs suggesting that she is getting worse, things such as retractions above the clavicles and between the ribs, the ability to speak only a few words at a time, and cyanosis, particularly of the lips and nail beds. After you transfer Andrea to the care of the emergency department staff, you return to service.

Signs and symptoms of a worsening condition might include an increase in the level of consciousness, more labored breathing, use of accessory muscles, tripod positioning, increased difficulty talking, a respiratory rate that is either too fast or toos slow, and increased patient anxiety. Signs and symptoms of an improving condition might include a "normal" respiration rate, the ability to talk in complete sentences, an alert mental state, absence of cyanosis, and a normal or improved oxygen saturation reading on the pulse oximeter

You and your partner agree that this patient needs to be rapidly transported to the trauma center. You are still maintaining manual stabilization of the patient's head and neck, so your partner gets a backboard and cervical collar. You perform a rapid physical exam from head to toe. The patient has abrasions on the left cheeck, the left wrist is swollen with pain on movement, and there is tenderness in both lower abdominal quadrants. Your partner takes a set of vital signs. You decide to do the past medical history in the ambulance. You immobilize the patient to the backboard with the head immobilizer in place. During this tranfer, you check the patient's back for any wound, bleeding, or tenderness. Once the patient is loaded in the ambulance, your partner starts toward the hospital with red lights and siren. The patient is still conscious, but he is having trouble talking in complete sentences. He reports a lot of discomfort. You think there may be pressure building up in his chest because of an injury to the lung. 5. What should be done for the detailed physical exam, if there is time before reaching the trauma center? You are confident that you need to treat the patient's worsening difficulty breathing. You lift the corner of the occlusive dressing and hear some air escape. The patient starts to breathe easier almost immediately. You take another set of vital signs. Then you secure the bandage over the chest wound again, but on only 3 sides. You turn your attention to the detailed exam, starting with the head, then moving to the chest and abdomen and finally ending with all 4 extremities and as much of the back as you can reach. With each location, you check for wounds tenderness, and deformities. The remainder of the transport is uneventful. You tranfer the patient to the hospital iwht an updated prehospital care report that includes the latest set of vital signs.

The ABCs remain the first priority. However, as time and patient conditions permit, the secondary assessment should include a head to toe survery.

SECONDARY ASSESSMENT OF TRAUMA PATIENT It's Saturday night and you've been assigned to one of the ambulances that covers downtown, where there is usually some kind of excitement going on. As you sit in quarters, you're listening to the scanner. The police seem to be busy with a variety of calls - disutrbances, domestics, and larcenies, to name a few. Then you hear on the on the police frequency: "Dispatch, we need an ambulance ASAP. We have a stabbing here." You don't wait for your pager to activate before you're in the ambulance bay with your partner. the pager follows shortly: "Delta 55, respond to 1512 Broadway, outside, for a stabbing. Police on scene and scene is secure." Your response takes only a few minutes. When you arrice, you see a male in his 20s lying on the sidewalk. "What happened?" you ask him. "Some punks punched me in the face and threw me into the stree when they stole my wallet." At this point, you tell the patient not to move his head and that you will help by manually stabilizing it. The patient continues," When I tried to fight them off, they stabbed me in the chest." The patient's airway is open, but he is out of breath and his breathing is rapid and shallow. You check the chest and see the entrance wound. You listen for breath sounds. there is silence on the side of the wound. You put on an occlusive dressing and administer oxygen by NR mask. You then rapidly check for external bleeding. 1. What is the priority of this patient?

The patient is suffering from multiple traumas. The ABC's are the priority is securing the airway and assuring adequate respirations. Due to facial injuires, you must make sure that mucus, blood and teeth are not causing airway obstruction. After applying a cervical collar and placing the patient on a backboard, you should suction as needed and if necessary, turn the patient on his side to allow for drainage. Next, you should apply an occlusive dressing over the stab wound. You should also provide the patient with high concentration oxygen, and if necessary, assist ventilation. Watch for the potential development of a tension pneumothorax throught the call.

It's Saturday night and you've been assigned to one of the ambulances that covers downtown, where there is usually some kind of excitement going on. As you sit in quarters, you're listening to the scanner. The police seem to be busy with a variety of calls - disutrbances, domestics, and larcenies, to name a few. Then you hear on the on the police frequency: "Dispatch, we need an ambulance ASAP. We have a stabbing here." You don't wait for your pager to activate before you're in the ambulance bay with your partner. the pager follows shortly: "Delta 55, respond to 1512 Broadway, outside, for a stabbing. Police on scene and scene is secure." Your response takes only a few minutes. When you arrice, you see a male in his 20s lying on the sidewalk. "What happened?" you ask him. "Some punks punched me in the face and threw me into the stree when they stole my wallet." At this point, you tell the patient not to move his head and that you will help by manually stabilizing it. The patient continues," When I tried to fight them off, they stabbed me in the chest." The patient's airway is open, but he is out of breath and his breathing is rapid and shallow. You check the chest and see the entrance wound. You listen for breath sounds. there is silence on the side of the wound. You put on an occlusive dressing and administer oxygen by NR mask. You then rapidly check for external bleeding. 2. What should be done next?

The patient needs rapid transport to a trauma center. After managing the airway and breathing, and controlling any external bleeding, you should package the patient for immediate transport.

SECONDARY ASSESSMENT OF MEDICAL PATIENT Just as you are about to sit down to eat lunch, you ambulance is dispatched to a local health club for a 50 year old female having an asthma attack. Upon arrival, you find the scene to be safe. Taking Standard Precautions, you are directed to the women's locker room, wher eyou find your patient sitting on a workout bench. "Hello. How can we help you today?" you ask. Your general impression is of alert middle aged woman in moderate respiratory distress. "Oh, I'm gaving an asthma attack," she says. You can see her airway is open, but her breathing is rapid and moderately labored. You observe no bleeding, find her skin to be normal, and determine her radial pulse to be slightly rapid but strong and regular. 1. What priority is this patient?

The patient presents with difficulty breathing, rapid respiratons, and rapid pulse. Unitl you can assess her condition further, you should consider her a high priority patient at this time

You and your partner agree that this patient needs to be rapidly transported to the trauma center. You are still maintaining manual stabilization of the patient's head and neck, so your partner gets a backboard and cervical collar. You perform a rapid physical exam from head to toe. The patient has abrasions on the left cheeck, the left wrist is swollen with pain on movement, and there is tenderness in both lower abdominal quadrants. Your partner takes a set of vital signs. You decide to do the past medical history in the ambulance. You immobilize the patient to the backboard with the head immobilizer in place. During this tranfer, you check the patient's back for any wound, bleeding, or tenderness. Once the patient is loaded in the ambulance, your partner starts toward the hospital with red lights and siren. The patient is still conscious, but he is having trouble talking in complete sentences. He reports a lot of discomfort. You think there may be pressure building up in his chest because of an injury to the lung. 4. What should you do next?

The patient seems to have developed difficulty breathing until you lift part of the occlusive dressing and allow some air to escape. This suggests tension pneumothorax. In this situation you should raise a corner of the occlusive dressing, which provides some relief. If this is successful, you should then continue to monitor the patient. Be prepared to assist ventilations, and if time allows, consider requesting ALS intercept.

5. What is your transport priority for the patient?

This patinet should be considered potentially unstable until you can gather more information. Transport should be expedited until you can rule out tthat he is not having a stroke, heart attack or serious diabetic emergency.

6. At what point would you call for an ALS intercept? Mr. Ronson is able to perform a Cinncinnati Prehospital Stroke Scale and does not show signs of stroke. Checking his blood glucose levels, you find a level of 32 mg/dL, which is significantly below normal. Because of his mental status, you are concerned about his ability to swallow, so you notify ALS and request an intercept. Fortunately they are close and respond before you leave the scene. They begin IV and administer 50 % dextrose. Mr. Ronson was joking again before he reached the hospital. The medics commend you for figuring out what was wrong and for the initial report when they got to the scene

You should call for an ALS intercept anytime the patient needs an ALS intervention such as intravenous dextrose.

You further find that Mr. Ronson lives alone. He was fine when he went to bed last night and was laughing and joking with the staff. His vital signs are pulse 58, strong and regualr; respirations 22 and adequate; blood pressure 164/92; pupils equal and reactive; skin warm and slightly moist. His medications all seem to match the conditons the staff reported. He has taken the meds with assistance from the staff. He has no known allergies and last ate yesterday afternoon. No one saw Mr. Ronson after he went to bed last night, so the event leading up to the current incident are unclear. He does appear to be able to follow your directions but not able to answer questions. 4. What assessments would you perform on this patient and why?

You should complete a full primary and secondary assessment along with an assessment of his mental status and nay pain or discomfort. USe the Cinncinnati Prehospital Stroke Scale to assess for signs of stroke

It's Saturday night and you've been assigned to one of the ambulances that covers downtown, where there is usually some kind of excitement going on. As you sit in quarters, you're listening to the scanner. The police seem to be busy with a variety of calls - disutrbances, domestics, and larcenies, to name a few. Then you hear on the on the police frequency: "Dispatch, we need an ambulance ASAP. We have a stabbing here." You don't wait for your pager to activate before you're in the ambulance bay with your partner. the pager follows shortly: "Delta 55, respond to 1512 Broadway, outside, for a stabbing. Police on scene and scene is secure." Your response takes only a few minutes. When you arrice, you see a male in his 20s lying on the sidewalk. "What happened?" you ask him. "Some punks punched me in the face and threw me into the stree when they stole my wallet." At this point, you tell the patient not to move his head and that you will help by manually stabilizing it. The patient continues," When I tried to fight them off, they stabbed me in the chest." The patient's airway is open, but he is out of breath and his breathing is rapid and shallow. You check the chest and see the entrance wound. You listen for breath sounds. there is silence on the side of the wound. You put on an occlusive dressing and administer oxygen by NR mask. You then rapidly check for external bleeding. 3. When should vital signs be taken?

You should take a baseline set of vital signs as soon as possible. Because the patient has a serious mechanism of injury, vitials should be retaken every 5 minutes.

Just as you are about to sit down to eat lunch, you ambulance is dispatched to a local health club for a 50 year old female having an asthma attack. Upon arrival, you find the scene to be safe. Taking Standard Precautions, you are directed to the women's locker room, wher eyou find your patient sitting on a workout bench. "Hello. How can we help you today?" you ask. Your general impression is of alert middle aged woman in moderate respiratory distress. "Oh, I'm gaving an asthma attack," she says. You can see her airway is open, but her breathing is rapid and moderately labored. You observe no bleeding, find her skin to be normal, and determine her radial pulse to be slightly rapid but strong and regular. 2. What are the next steps in the management of this patient?

You should take a basline set of vitals, as indicated in the opening part of the scenario. After eliminating any immediate life threats, you should begin to gather a history of the present illness, focusing on questions that pertain to the condition cited by the patient. Administer oxygen, assess for its effect on the patient, and check the patient's pusle oximetry reading